136-805 / Implementation of perceived quality committees in hospitals

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Madrid Health Service


Quality improvement project

GOP Description
Implementation level
Clinical settings
35 hospitals
OBJECTIVE: To improve the citizens’ perceived quality of healthcare
• Improve customer satisfaction and complaisance with the process of care received
• Raise awareness among employees about the importance of the user’s opinion on quality improvement.
• Promote quality culture within the organization, taking into account the user’s perspective.
Professional health centers
1. – Preparation of a paper on Recommendations for the Implementation of the Committees on Perceived Quality in Madrid Health Service which includes guidance on the composition, functions and implementation of the Committees.
2. – Inclusion of the following quality objectives in the annual program contract with hospitals : Constitution of Committee (2009) and development of the same lines of action (2010 and beyond).
3. – Annual Conference on the contribution of Perceived Quality Committees to continuous improvement in hospitals
Timeframe implementation
2009: Constitution of Committees in each of the hospitals
2010: Launch of the Committees (at least 3 meetings)
Years 2011 and up to the present: Implementation of at least four courses of action each year
Implementation tools available
Available document: Recommendations for the Implementation of the Committees on Perceived Quality in Madrid Health Service.
Annual Contract objectives established between Madrid Health Service and each hospital
Implementation cost
No one can estimate a direct cost. In terms of resources, requires part-time participation of a multidisciplinary team, which at least has the management team representative, unit quality, patient service, the medical, nursing area and management area among others.
Method used to measure the results
Evaluation through indicators of program contract hospitals and report of each hospital with description of guidelines developed
100% of hospitals have formed the Committee.
The analysis of the views of users, along with the information provided by the center workers have allowed Perceived Quality Committees lines have driven improvement in areas of: improving information to patients and family formation professional collaboration with the community, etc.
In the years 2011 and 2012 were developed respectively: 181 and 176 lines of action.
These actions are complemented by monitoring the actions set by the centers as a result of the annual survey of satisfaction of users of the Madrid Health Service.
Analysis of the results
-The establishment and implementation of the committees in all hospitals, comprising multidisciplinary professionals, has proved an operational tool for improving the perceived quality. It serves as a collection area, debate and analysis of problems related to the quality perceived by users and guests and also to prioritize, identify and propose actions to improve the perceived quality
Implementation barriers
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Other information
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